Antidepressant ABCs

Antidepressants can be lifesavers, washing away the chronic despair and anxiety that threaten countless Canadian women. But if you or someone you love is taking them, you may be concerned about side effects, especially given a recent Health Canada advisory flagging suicide as a possible reaction to certain antidepressants such as Prozac and Paxil. The United Kingdom is also advising against antidepressants for people under 18, as studies show that risks may outweigh benefits for this group.

Don't panic. And if you think you're depressed, but alarming reports keep you from getting help, don't let them. Antidepressants save thousands of lives every year, says Dr. Shaila Misri, a professor of psychiatry, obstetrics and gynecology at the University of British Columbia in Vancouver. And potential side effects are manageable in all but 15 per cent of people who respond to antidepressants. The real problem, says psychiatric pharmacist Wende Wood at the Centre for Addiction and Mental Health in Toronto, is the lack of understanding about depression and how antidepressants work. So, what do you need to know?

About 25 per cent of women will experience a bout of depression, anxiety or both in their lifetime; however, fewer than half will seek treatment, and many will be incorrectly diagnosed. "People think of depression as being sad and crying all the time," says Wood, "but the illness can involve aches and pains and being tired all the time, too."

A recent survey presented by the Canadian Network for Mood and Anxiety Treatments found that fatigue is the most common and debilitating symptom of depression, before and after treatment.

Other symptoms include changes in sleep, headaches, a feeling of hopelessness and thoughts of suicide, says Dr. Misri. Talk to your doctor about physical symptoms such as these, or if you've experienced a depressed mood for at least two weeks.

Once correctly diagnosed, half of all depressed patients will need to try two or more different antidepressants before finding one that works and has tolerable side effects, says Dr. Anthony Levitt, psychiatrist-in-chief at Sunnybrook and Women's College Health Sciences Centre in Toronto. Doctors have little way of knowing which drugs work best for whom, and it can take four to six weeks to tell if an antidepressant is doing the job. In the meantime, you may have to cope with side effects, such as nausea and anxiety, which are typically more severe at the outset (Commonly prescribed antidepressants see Commonly prescribed antidepressants). Lately, Wood adds, physicians have begun prescribing lower doses of two antidepressants at the same time. While it increases the number of side effects you might experience, the severity of those side effects may be reduced.

For the uninformed, the drug trial period can be a crushing letdown, as well as physically exhausting. Karen Liberman, executive director of The Mood Disorders Association of Ontario in Toronto, is an extreme example. She had to try 26 different antidepressants, starting with Prozac when it hit the market in 1986, before finding the right match for her, Remeron. But Liberman never gave up, despite, as she says, "the vicious nature of the illness, which tells you it's your fault when a drug doesn't work."

Once you find an antidepressant that works for you, your physician may still need to fine-tune the dosage to tone down side effects, says Wood. Recommended dosage varies for each antidepressant and for each patient. "Some people can get up to a full dose within a few days," says Wood. "For others, it can take a few weeks.

"It is really quite shocking how many people who get side effects won't go back to their doctor," Wood says. "They just stop taking the antidepressant." A study in the Canadian Journal of Psychiatry shows that as many as 44 per cent of patients stop taking their medication by the third month of therapy. Common reasons: fear caused by side effects or the erroneous belief that the depression was cured.

While Health Canada contends antidepressants are not addictive, your physician will need to wean you off them by lowering the dosage. Quitting the drugs suddenly can result in withdrawal symptoms, including extreme anxiety, flu-like feelings, electrical sensations and thoughts of suicide. Health Canada also cautions pregnant women against quitting their drugs without consulting their physician, despite its recent warning that antidepressants may have adverse effects on newborns such as jitters, seizures and feeding and breathing problems. Still, according to Wood, the benefits of staying on antidepressants during pregnancy may still outweigh the risks of quitting them.

Experts say the most important thing you can do when on antidepressants is continually consult with your physician. "Try to see your doctor once a week for at least the first three or four weeks of treatment," says Dr. Misri. How do you know when you've found your fit? Ideally, the drug makes you feel as you did before you were depressed with no, or few, side effects.

Medication alone won't be enough to cope with depression. While not every patient needs therapy, according to Dr. Misri, people should seek out some support—even if it's just talking to a doctor and supportive friends. "Some people expect antidepressants to cure everything. They don't," says Wood.

Research is demonstrating that combining depression treatment with a healthy lifestyle—including regular exercise—can help recovery, adds Dr. Misri. So, try to address unfulfilling jobs or relationships, maintain good sleeping patterns and learn stress management skills.

Wood says you can expect to be on an antidepressant for one year to treat your first episode of clinical depression. Fifty per cent of people treated successfully for one bout of depression will never experience the illness again. But if you have a second episode, antidepressants for two to five years can help. You and your doctor may decide that you take the drug indefinitely.

Liberman will never quit her medication because if she gets ill again, the same drug may not work a second time. Taking medication for mental illness is no different from taking medication for diabetes or thyroid disease, she says. "After seven years on my medication," she adds, "in my heart of hearts, I believe I've beaten this."

Use the chart below to find out about side effects of the most commonly prescribed antidepressants and what not to mix with them, according to the Centre for Addiction and Mental Health in Toronto.
Note: side effects vary for each individual.

Commonly prescribed antidepressants
DRUGS	SIDE EFFECTS	AVOID
citalopram (Celexa); fluoxetine (Prozac); fluvoxamine (Luvox); paroxetine (Paxil); sertraline (Zoloft)	nausea, insomnia, headaches, sexual dysfunction, jitters/restlessness, dry mouth, drowsiness	St. John's wort; monoamine oxidase inhibitors (MAOIs); antidepressants such as phenelzine (Nardil) and tranylcypromine (Parnate); alcohol, which can increase side effects; and caffeine, which may trigger anxiety and insomnia
venlafaxine (Effexor, Effexor XR)	sedation, insomnia, headaches, dry mouth, constipation, sweating, dizziness, nausea, sexual dysfunction, increased blood pressure	MAOIs; alcohol, which can increase side effects; caffeine, which may heighten anxiety and insomnia. Use with caution if you have hypertension
mirtazapine (Remeron)	sedation, fatigue, dry mouth, constipation, increased appetite, weight gain	MAOIs; alcohol, which can increase side effects. Dosage adjustment may be required if taken with carbamazepine (Tegretol, Tegretol-XR)
bupropion (Wellbutrin SR, Zyban)	jitters, insomnia, headaches, dry mouth, nausea	MAOIs; stimulants. Epileptics may suffer increased seizure risk